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In Barbara Kingslover's novel, The Poisonwood Bible,1 a preacher from the southern United States, along with his wife and young daughters, embarks on a mission trip to the African Congo. Here he attempts to recreate the bountiful gardens of his homeland by planting beans, squash, and tomatoes. The richness of the soil assures him that abundance is but a few weeks away. He delights in seeing the seeds sprout, stems form, and leaves grow. Time passes, blooms appear, opening and closing, the green fruits behind them shriveling and turning brown. The blooms do not set fruit. To his dismay, he realizes that there are no pollinators-no native insects that can successfully pollinate the plants from a foreign land. Native African insects are large and plentiful-but what, muses the preacher, does an African bug know of a Kentucky Wonder bean?


The botany lesson imbedded in this novel spurs a metaphoric discussion. How do clinical nurse specialists (CNSs) "pollinate" nursing practice, so to speak, to assure that the sprouts and leaves of new knowledge about diagnosis and treatment of symptoms, functional problems, and risk behaviors yield the flowers of innovative nursing interventions. How do CNSs pollinate or influence the practice of other nurses and the healthcare systems to assure that interventions in turn manifest fruit in the form of quality nurse-sensitive outcomes.


There has been an explosion in nursing knowledge generated by research. In a comprehensive review of the literature, Donaldson2 identified significant breakthroughs in nursing knowledge over the past 40 years. She defined nursing knowledge as knowledge from the perspective of nursing that focuses on phenomena of humans, as individuals or personal social groups, and their health, including health status, health-related behaviors, health determinants, and dynamics of health. This nursing perspective, she points out, is distinct from the medical perspective of human disease (function or status of human cells, organs, or organ systems per se) and the discipline of public health, which addresses the health of large aggregates of human who do not necessarily have a personal relationship. Donaldson's examples of significant breakthroughs include (1) a shift in person and family health toward a focus on the way in which autonomous individuals, family members, and families interact and adapt over time to changes in health status; (2) recognition that pain intensity and degree of distress from pain are separate components of pain, that uncontrolled pain can kill, and that pain perception differs by gender; (3) greater emphasis on an ecological perspective of human development in neonatal and young child development; (4) creating a focus on quality of life, autonomy, behavior management, and caregiver support for persons with dementia and their families; (5) significant improvements in patient outcomes related to nurse specialist care in home follow-up and care transitions; (6) shifting the perspective of human violence behavior to that of interpersonal violence and family system dysfunction in the context of societal influences; (7) refocusing women's health from the biomedical function of female organs and systems to women's personal health experiences; (8) expanding interventions for urinary incontinence and inclusion of behavioral, biophysical, and environmental options to address both the physical problem and associated distress; (9) demonstrating effectiveness of nursing interventions for health-related nondisease stressors that affect the immune system using a psycho-neuro-immunological framework; and (10) expanding biobehavioral health interventions such as exercise and other activities to reduce risk for disease and moderate symptom distress.


Donaldson's examples of scientific breakthroughs create both an impressive list and a daunting challenge for CNSs bringing new knowledge to nursing practice. Two practice models are available for transferring knowledge to practice. In the expert provider model, a CNS implements cutting edge, knowledge infused, evidence-based nursing interventions to individual patients. In this model, a CNS is a direct care provider for patients with problems amenable to nursing interventions. This model supports bringing new scientific knowledge to the design, implementation, and evaluation of nursing interventions by linking patients to a single expert provider.


A second model, the diffusion model, directs a CNS to move expert care beyond himself/herself as singular provider and to create and share with other nurse providers cutting edge, knowledge infused, evidence-based interventions. In the diffusion model, expert innovative nursing care is diffused to other nursing care providers for the purpose of improving individual care across time or setting, or changing norms and standards of care for specialty populations with predictable patterns of problems.


CNSs use both models with varying emphasis to advance the practice of nursing. Which model a CNS uses, individually or in combination, depends on factors that include problem intensity, population, and setting. Both practice models are grounded in the CNSs' scope of practice that includes designing and implementing innovative nursing interventions for problems amenable to nursing interventions, or interventions within nursing's autonomous scope of practice-innovative interventions that are directed by scientific breakthroughs in knowledge from the perspective of nursing.


Grounding both models in nursing's autonomous scope of practice is important. The innovative nursing interventions created by CNSs are personally delivered in the single provider model, but importantly, are shared with other nurses in the diffusion model. If CNS practice was a separate and unique legally defined scope of practice different from nursing's existing scope of practice, then diffusion of innovative interventions would be compromised because CNS interventions would be limited to the CNS scope. The result would be a sort of parallel play-with CNSs singularly providing care disconnected from the larger universe of nursing practice of the registered nurse. What then is the value of a CNS practicing nursing at an advanced level if not to advance the practice of nursing?


For the preacher with the pollination problem, his daughter thoughtfully suggested that he should have brought bees from his native Georgia along with the seeds. Such is not the case for nursing today. CNSs are the pollinators-the advanced practice nurses whose responsibilities are to assure that nursing practice is evidence-based; that new knowledge is diffused or transferred into the CNSs' practice with patients and into the practice of other nurses, thereby changing the practice norms of an individual system and by influencing standards of practice within the profession. Through CNS practice the metaphoric fruits of innovative evidence-based interventions on quality nurse-sensitive outcomes will become a reality. And you can read all about it here in the journal-a venue for CNSs to diffuse information about interventions driven by knowledge from nursing's unique perspective!!




1. Klingsover B. The Poisonwood Bible. New York: Harper-Collins Publisher; 1998. [Context Link]


2. Donaldson SK. Breakthroughs in scientific research: the discipline of nursing 1960-1999. Annu Rev Nurs Res. 2000;18: 247-311. [Context Link]